Carlton Plaza of Davis

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to continue a case management and gather information/records regarding incidents on 4/19/2026 self reported by the facility on 4/20/2026 that involved staff S1, S2, S3 and residents R1 and R2. LPA met with Executive Director Blaine Lyons and collected video files. Exit interview conducted and copy of report left with Executive Director.the state’s words, verbatim · CDSS document, Apr 30, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to continue a case management regarding an incident that occurred on 04/19/2026. LPA met with Executive Director Blaine Lyons. LPA requested the following information/records for Community Care Licensing regarding incidents on 4/19/2026 self reported by the facility on 4/20/2026. * LIC500 * Video of Incident * Termination Forms * LIC855 - Declaration Forms Exit interview conducted and copy of report left with Executive Director.the state’s words, verbatim · CDSS document, Apr 24, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a case management visit and gather information/records regarding incidents on 4/19/2026 self reported by the facility on 4/20/2026 that involved staff S1, S2, S3 and residents R1 and R2. LPA met with Executive Director Blaine Lyons, took statement and requested records for Community Care Licensing to review incident. LPA reviewed video surveillance footage of the common area in the Memory Care Unit from 04/19/2026 and observed staff S1, S2 and S3 caring for residents including R1 and R2. The video shows that during the shift S1 employed the use of a bench to prevent R1 from moving off of couch and S2 and S3 moving R2 to a wheelchair and using a seatbelt to secure R2 to chair. While these restraints were used residents were continually being cared for and supervised by staff. It was observed that the restraints were removed at the arrival of the AM shift by staff S4. LPA inspected the Memory Care Unit of the facility and found it to be clean and a comfortable temperature, with protocols in place for safe Dementia Care, including no access to hazardous materials, toxins or sharps and no use of unauthorized restraints. LPA and Executive Director discussed ongoing training with staff. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 21, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(4) · Plan of correction due date: Apr 21, 2026

87608 Postural Supports (a)...Postural supports may be used under the following conditions. (1) ....used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirement not met by licensee as evidenced by: LPA observation of bench and postural support used as a restraint, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 21, 2026

Plan of correction: Admin to submit self-certifying all facility staff will immediately cease using postural supports as a restraint by plan of correction due date of 4/22/2026.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Jill Nakagawa, arrived at facility unannounced to conduct a case management visit regarding a self reported incident report and SOC341 dated 02/23/2026. LPA met with the Administrator, Blaine Lyons and Mina Kutulas, Director of Resident Services. Administrator made a police report (Case #26-738), contacted responsible party of R1, conducted an internal investigation, reached out to R1's health team. LPA toured the facility, made observations, reviewed records and conducted interviews. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Feb 24, 2026

Type of visit: Required - 1 Year

On 01/22/2026, Licensing Program Analyst (LPA) Jill Nakagawa, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Blaine Lyons, Administrator and explained the purpose of the visit. LPA Nakagawa and Mina Kutulas, Director of Resident Services toured facility together to ensure health and safety of residents in care. Areas toured included but are not limited to: common areas, resident bedrooms of Memory Care unit, common restrooms, kitchen, dining room, activities rooms and several resident apartments. LPA observed the facility to be clean, in good repair and odor-free. Each bathroom inspected was equipped with the necessary grab bars, non-skid flooring or shower chair, paper towels and hand soap. Water temperature measured approximately 113 degrees F throughout the facility, which is within regulation. LPA observed each bedroom to have the necessary furnishings with working lights and windows with screens. LPA observed organized activities held throughout the day in Memory Care and outings planned for Assisted Living. The dining area was clean and sanitary and the layout made it easy for residents with walkers and wheelchairs to access the tables and move about to socialize. The newly renovated Great Room had an operating fireplace with screen, and comfy chairs set up for easily accessed social spaces. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. LPA observed several fire extinguishers which were fully charged and last serviced on 1/11/2026. Fire inspection of fire/smoke detectors as well as fire drill for all shifts was held on 1/11/2026. In the areas toured no immediate health, safety, or personal rights violations were observed. Continued on 809-C.... Continued from 809... LPA reviewed a total of five (5) residents' files and five (5) staff files which contained all the required documentation. Resident files were on-line but are accessible by staff at any time. LPA was able to find all required documentation. Several topics were discussed including the interactive Memory Care activities program. No deficiencies are being cited as a result of today’s inspection.the state’s words, verbatim · CDSS document, Jan 22, 2026

Type of visit: Case Management - Incident

At approximately 9:20 AM, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Blaine Lyons. The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 11/17/2025. The report stated that on 11/16/2025, Resident (R1), who has a diagnosis of dementia and is unable to leave facility unassisted, eloped from community at 8:31 AM, according to surveillance video. Staff immediately responded to R1’s security bracelet at the front door alarm. Staff were alerted to R1’s elopement at 8:31 AM and staff pursued R1, losing sight of R1 in the adjacent neighborhood. Administrator, police and family were notified. R1 was found safe at relative's house close to the facility. R1 was released to staff and returned to the facility. R1 was not in need of medical attention. Per R1’s Physician’s Report (LIC602) R1 is diagnosed with dementia and is unable to leave the facility unassisted. (Deficiency cited) Civil Penalty for $1,000.00 was issued during today's visit for a repeat violation, Absence of Supervision. Deficiency cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.the state’s words, verbatim · CDSS document, Nov 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 18, 2025

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: Based on incident report and interview, facility failed to maintain line of sight, which was a lack of supervision to R1 resulting in an elopement. The absence of supervision is an immediate risk to the Health, Safety and Rights of resident in care.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: Administrator submitted plan to CCL on 11/18/2025 re: conducting ongoing in-service training about elopement procedures, and will self-certify that all alarms, delayed egress, and sensors for Wander Guard are functioning at each shift change.

Type of visit: Case Management - Other

LIcensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced case management and met with Administrator Blaine Lyons. The purpose of this case management inspection is to follow up on an Immediate Exclusion from the facility for Staff (S1). LPA provided a copy of the letter "Order to Licensee/Facility of Immediate Exclusion from Facility" dated September 19, 2025 for S1. Documentation shows S1 was employed briefly; last day of employment was 02/21/2023 and is no longer employed by Carlton Plaza of Davis and is not present in the building. Based on evidence obtained during today's visit, the LPA has verified the individual is not present, working at or residing at the facility #577005341. A check of the Guardian Roster verified that S1 was not listed as an employee. No deficiencies cited during today's inspection. Copy of letter provided to Blaine Lyons, Administrator.the state’s words, verbatim · CDSS document, Sep 23, 2025

Allegation investigated: Staff do not respond to residents' call for assistance in a timely manner Staff do not follow residents' care plan

On July 1, 2025, Program Analyst (LPA) Nakagawa arrived unannounced to continue a complaint investigation and deliver findings on the above allegations. LPA spoke with Administrator Blaine Lyons. The complaint alleges that Staff do not respond to residents’ call lights for assistance in a timely manner. LPA requested call light records for 1/20/25 through 2/19/2025. There were 310 calls in Memory Care for that time frame. LPA looked at a sample of the records for 1/20/25 through 1/23/25 and found 59 calls; with 53 of those calls being answered within 1-4 minutes. There were 4 calls that took between 13-38 minutes and 2 calls that took between 1 hour and 11 minutes and 1 hour and 15 minutes. Although most of the response times were well within best practices, the two calls that took over an hour demonstrate that Staff do not respond to residents’ calls for assistance in a timely manner; other days examined within the time frame of 1/20/25 to 2/19/25 had similar findings: 2/13/25 through 2/18 /25 showing responses to 61 calls with 53 taking less than 10 minutes, Continued on 9099-C Substantiated Continued from 9099.... 6 taking 15 to 44 minutes and three calls taking from 1.56 hours to 3 + hours therefore the allegation is substantiated. (See 809D for the deficiency cited). The complaint alleges Staff do not follow the resident’s care plan. The complainant states some residents’ care plans state they need 2-person assistance due to needing a Hoyer lift, or for incontinence care, and staff have been told to do it on their own. The complainant stated resident R2 is a fall risk, and management said they need to be watched one on one. The complainant stated that it wasn’t communicated to all staff, and R2 fell out of bed 2/13/25. LPA spoke with staff S1 who reported that R2 had enhanced care services 1:1 between 1/22/2025 until 5/13/2025, which were clearly listed in the care plan which is completed by care staff members. The care records for R2 show they had enhanced care services and were receiving additional supports including escorts to and from activities and meals, mealtime support, hourly checks. According to S1, on 2/13/2025 R2 didn't fall but slid out of bed; there were no injuries (the facility utilizes Safely You camera). LPA conducted interviews and found that 6 out of 6 staff stated the company policy for care staff who are providing care independently must ask for assistance from another staff member when providing care for a Hoyer lift or a 2-person assist. Zero of 6 staff stated that they were instructed to initiate care alone for a two person assist. However, 2 of 6 staff members interviewed stated that if they did not receive a timely response to their request for assistance the staff member would aid the resident alone, despite the company policy. Therefore, the allegation that staff do not follow the care plan is substantiated. (See 809D for the deficiency cited). Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Continued on 9099-A Continued from 9099-A Medication list does show barrier cream to be applied once per day but makes no reference to any redness or other concerns. Therefore the allegation that Staff do not ensure that resident is repositioned is unsubstantiated. The complaint alleges Staff do not prevent residents from engaging in inappropriate behavior. The reporting party stated 2 residents (R3 and R4) were found in bed together. Based on interviews LPA found that staff did not anticipate the behavior of residents R3 and R4. During a group activity staff noticed R3 and R4 missing from an activity and when they went to check on them R3 and R4 were found together in bed; an activity within their personal rights. There was no incident report filed citing any abuse or misconduct, and responsible parties were notified. Although it may have been unanticipated residents were exercising their personal rights - not engaging in inappropriate behavior, therefore the allegation that Staff do not prevent residents from engaging in inappropriate behavior is unsubstantiated.the state’s words, verbatim · CDSS document, Jul 1, 2025 · control 21-AS-20250219114000

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jul 1, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to meet resident needs.....for the provision of adequate services. This requirement was not met as evidenced by: Based on interviews and record review,LPA observed Call Light logs from January 20, 20253 through February 19, 2025 in which residents would push the call buttons and the response times were exceeding over 60+ minutes. This is a potential health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: Plan of Correction shall include a plan for retraining Memory Care staff as it relates to answering call lights in a timely manner. In addition, Administrator discussed with LPA a plan for going forward with re-training completed by 7/8/2025.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.2(b) · Plan of correction due date: Jul 1, 2025

Health and Safety Code section 1569.2(b):(b) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not met as evidenced by: Based on interviews, staff ignored company policy of using 2-person assist when care plan called for a 2-person assist and worked independently, not waiting for assistance.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: Plan of Correction shall include a plan for retraining Memory Care staff as it relates to 2-person assists. Administrator will submit proof of training to LPA by 7/8/2025.

Type of visit: POC

On 05/15/2025, Licensing Program Analyst (LPA) Jill Nakagawa, arrived at the facility unannounced to conduct a Plan of Correction (POC) inspection. LPA met with Director of Resident Services, Mina Kutulas and explained the purpose of the visit. Administrator Miriam Faris was out of the facility but available by phone. LPA Nakagawa and Mina Kutulas toured facility together to ensure health and safety of residents in care. The Memory Care unit was staffed with 2 activities personnel, one staff as a one-on-one for a resident in care, 32 residents and 7 staff plus the Director of Memory Care. The unit was clean, the residents were clean and dressed appropriately, with many of them participating in activities in the main living room. LPA and Mina Kutulas inspected the patio area. Door alarms were working and loud enough to be heard. The outside gate which has a delayed egress was also checked. A new audible alarm was added which rings loudly and distinctly in the living room any time the delayed egress is opened, which will alert staff throughout the unit. POC has been cleared. No deficiencies found at the time of inspection. No citations issued.the state’s words, verbatim · CDSS document, May 15, 2025

Allegation investigated: Staff are not taking precautions to mitigate the spread of illness in the facility

Licensing Program Analyst (LPA) opened an investigation regarding the above allegation and found the following through the conducting of interviews and reviewing documents. The Administrator stated that the facility’s Infection Control Plan abides by the strictest protocols in place when giving care to residents. On 12/30/2024 the Administrator was aware of resident (R1) experiencing vomiting, and diagnosed with pneumonia. This was reported to CCL on 1/08/2025. There were no other cases reported to CCL until 1/31/2025. Administrator informed CCL by email that there were several residents with GI issues. Residents were notified by written notice posted at their doors of the increase in cases, courtesy room service was extended to all residents; dining room remained open. (Continued on 9099-C) Substantiated (Continued from 9099...) According to Administrator, Yolo County Dept. of Public Health (CDPH) was also contacted on 1/31/2025 and a line list of cases submitted to CDPH on 2/1/2025 and CCL on 2/3/2025. According to the line list there were four cases of vomiting and/or diarrhea which had been reported to Administrator on 01/28/2025. CCL and CDPH guidelines require notification within 24 hours when there is an outbreak (3 or more cases). The allegation that Staff are not taking precautions to mitigate the spread of illness in the facility is substantiated. Based on review of records the preponderance of evidence standard has been met: Administrator did not notify the Department in the required timeframe therefore the above allegation is found to be SUBSTANTIATED. (Deficiency cited) Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and Health and Safety Code (cited on 9099-D). Appeal rights given to the former Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.the state’s words, verbatim · CDSS document, May 6, 2025 · control 21-AS-20250131155017

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(2) · Plan of correction due date: May 6, 2025

87211 (a)A written report shall be submitted to the licensing agency...within seven days of the occurrence of.. (2)Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidenced by: Based on reporting records Licensee did not report outbreak within the required 24 hours.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Administrator discussed plan for training with LPA on 5/6/2025. Administrator to conduct in-service training with all care staff and management team on the proper reporting requirements as outlined in CCR 87211. Administrator will submit a signed training log with names of attendees, date, time, location and subject of the training, and who conducted the training to CCL by POC due date 05/12/25.

Type of visit: Case Management - Incident

****This is an Amended 809*** At approximately 9:20 AM, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Miriam Faris. The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 04/23/2025. The report stated that on 04/20/2025, Resident (R1), who has a diagnosis of dementia and is unable to leave facility unassisted, eloped from community at 4:26 PM, according to surveillance video. Staff failed to respond to R1’s security bracelet and the side door alarms. Staff became aware of R1’s elopement at 6:45 PM; Administrator, police and family were notified. Davis Police notified community that resident was found safe off premises 2.4 miles away inside a store. Administrator went to location of R1 and met with police. R1 was not in need of medical attention and released to Administrator, who transported R1 back to community. Per R1’s Physician’s Report (LIC602) R1 is diagnosed with dementia and is unable to leave the facility unassisted. (Deficiency cited) Civil Penalty for $500.00 was issued during today's visit for Zero Tolerance, Absence of Supervision. See LIC809-D for Deficiency. Exit interview conducted with Administrator and a copy of this report along with LIC811 (Confidential Names) was provided.the state’s words, verbatim · CDSS document, May 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 6, 2025

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: Based on incident report and interview, facility failed to provide supervision to R1 resulting in an elopement. The absence of supervision is an immediate risk to the Health, Safety and Rights of resident in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Administrator submitted plan to CCL on 5/6/25 re: conducting ongoing in-service training about elopement procedures, and will self-certify that all alarms, delayed egress, and sensors in memory Care are functioning by submitting a check-off list for Evening Supervisor to complete each shift to ensure lights and sensors are 100% operational. Also, a plan was submitted to CCL on 5/6/2025 for the maintenance of all alarms, delayed egress and sensors in Memory Care. ****A civil penalty is being assessed for $500.00.

Type of visit: Required - 1 Year

On 02/04/2025, Licensing Program Analyst (LPA) Jill Nakagawa, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Resident Care Director Mina Kutulas and explained the purpose of the visit. LPA Nakagawa and Mina Kutulas toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms of Memory Care unit, common restrooms, kitchen, dining room, actvities rooms and several resident apartments. LPA observed the facility to be clean, in good repair and odor-free. Each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids. LPA observed each bedroom to have the necessary furnishings with working lights and windows with screens. LPA received multiple compliments from AL residents regarding care and food. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. LPA observed several fire extinguishers, fire/smoke detectors. LPA observed the first aid kit to be complete and ready for use. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA reviewed a total of five (5) residents' files and five (5) staff files which contained all the required documentation. Resident files were on-line but are accessible by staff at any time. LPA was able to find all required documentation. Several topics were discussed. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Feb 4, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jill Nakagawa arrived on February 4, 2025 for an unannounced Case Management visit to follow up on substantiated complaint allegations: complaint number 21-AS-20230724142905. LPA met with Miriam Faris, Administrator and explained the purpose of the visit. On January 9, 2024, the Department concluded an investigation which alleged that Neglect/Lack of Care and Supervision resulting in severe injury and Facility in disrepair. The allegations were substantiated, and the licensee was cited for violating Health and Safety Code (H&S) §1569.269(a)(6) Enumerated rights; and California Code of Regulations (CCR) Title 22 §87303(a) Maintenance and Operation. At the time of the complaint visit on January 9, 2024, an immediate civil penalty for Health and Safety Code §1569.269(a)(b) of $500 was issued. The licensee was informed that an additional civil penalty was being determined and might be assessed based on Health and Safety Code §1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code §15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facilities lack of supervision on February 17, 2023, when a resident (R1) who was identified as a fall risk and required additional supervision, was able to exit the patio door, go outside unsupervised and fall. Continued on 809-C Continued from 809.... Staff (S1) last observed R1 at approximately 1800 hours sitting in a wheelchair near the patio door. Staff (S2) reported that on February 17, 2023, at approximately 1800 hours, surveillance video showed R1 exit the patio door and go outside unsupervised. Staff (S3), who was covering for S4 who was on break, was observed on camera in the living room area close to the patio door and did not turn around or respond to the patio door alarms. While outside unattended on the unlit patio for approximately one and a half hours, R1 fell and sustained a fractured hip resulting in hospitalization and surgery. Today February 4, 2025, the Department is issuing a civil penalty per Health and Safety Code §1569.49 for a violation that the Department constitutes as serious bodily injury resulting in the hospitalization of a resident, in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on January 9, 2024, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report has been issued. Appeal rights provided. Facility representative and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Feb 4, 2025

Allegation investigated: Staff do not ensure residents toileting needs are met in a timely manner Staff are not providing residents with adequate food service Staff do not keep the facility free from odor Staff did not address changes to resident's physical, medical, mental, and social condition

On 10/19/2024 LPA Nakagawa arrived unannounced to conclude an investigation and deliver findings regarding the above allegations. LPA met with the acting facilities director of the day, Genai Bradshaw, Memory Care Activities Director. The complaint alleges that staff are not providing residents with adequate food service. LPA conducted facility visits on 07/24/2024 and 10/19/2024. LPA observed breakfast and lunch service in the memory care (MC) and assisted living units (AL). LPA observed an ample supply of food, which appeared to be varied and of high quality, meeting the nutritional standards as required per Title 22. LPA observed staff assisting residents who required help with feeding; staff prompted or assisted residents as needed. In addition to 3 meals a day, there are also snacks and hydration breaks available throughout the day. Continued on 9099-C Unsubstantiated Continued from 9099.... Based on LPA’s observations, interviews, and records reviewed, there is no evidence to support the allegation that staff are not providing residents with adequate food service. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Staff did not address changes to resident's physical, medical, mental, and social condition. LPA made observations, conducted interviews, and reviewed records and found that staff monitor all residents for changes in condition. LPA reviewed physician reports and care plans. The care team is aware of residents’ needs and continuously monitor for changes in condition and did not find any evidence of changes not being addressed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur therefore the allegation that staff did not address changes to resident’s physical, medical, mental, and social condition is unsubstantiated. Staff do not keep the facility free from odor: LPA conducted facility visits on 7/24/2024 and 10/19/2024 and found resident rooms in memory care to be clean and odor-free. LPA inspected rooms in the Assisted Living section on the same dates and found no concerns for cleanliness or observed any odors. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation that Staff do not keep the facility free from odor is unsubstantiated. Staff do not ensure residents toileting needs are met in a timely manner: LPA made observations and reviewed records. LPA conducted facility visits on 07/24/2024 and 10/19/2024 and found that residents appeared clean and dressed appropriately. A review of records found that hygiene and toileting needs are logged regularly by staff which show that toileting is conducted approximately every two hours. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation that Staff do not ensure residents toileting needs are met in a timely manner is unsubstantiated.the state’s words, verbatim · CDSS document, Oct 19, 2024 · control 21-AS-20240722163924

Type of visit: Office

An informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager, Kimberley Mota, Licensing Program Analyst, Jill Nakagawa, Administrator, Miriam Faris, Vice President of Corporate Development, Lindsay Flores and, VP Clinical Operations, Marco Santos. The purpose of the informal meeting was to discuss an incident that occurred at the facility on February 17, 2023 that resulted in a complaint investigation with substantiated findings. In addition, the following areas of concern were discussed: *Adequate staffing in the memory care unit: training of staff to include understanding the importance of staggered breaks. In addition, Administrator to monitor the care needs of residents and proper staffing levels to meet these needs. *Administrator's Duties: Administrator to ensure adherence to reporting requirements, ensuring safety of buildings and grounds. Administrator has implemented: Evening supervisor (2:30 PM to 10:45 PM) whose primary duty is not to provide care giving (although they are trained if needed), but to oversee evening operations. In addition Administrator states that facility has implemented a "hero position" which is an additional staff member where needed. Continued on LIC809-C Documents requested during informal meeting to be submitted to CCL by May 31,2024.: · Licensee will submit an updated LIC500 indicating staff coverage in all areas of the facility.. No deficiencies cited during today’s informal conference office visit.the state’s words, verbatim · CDSS document, May 30, 2024

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Stefanie Mutialu and Jill Nakagawa arrived unannounced at Carlton Plaza of Davis to conduct a Case Management - Inspection. The purpose of this case management visit was to follow up on self reported incident report that was submitted to Community Care Licensing (CCL) regarding residents R1 and R2. During visit LPA went over incident details, gathered records, took statements from Administrator. Facility has been in contact with Police, CCL and Ombudsmans' Office. LPA will review information and will follow up with facility, once additional information is gathered and reviewed. No deficiencies were found at the time of visit. No citations issued.the state’s words, verbatim · CDSS document, Mar 8, 2024

Allegation investigated: Neglect/Lack of Care and Supervision resulting in severe injury Facility in disrepair

Licensing Program Analyst Nakagawa arrived unannounced to deliver findings of an investigation regarding the allegations that the facility’s neglect resulted in resident’s injury and that the facility is in disrepair. The Department conducted an investigation which revealed that Staff (S1) reported that on 2/17/2023, at approximately 1800 hours, surveillance video recordings showed Resident (R1) exit through the facility's patio door leading outside unsupervised. At the same time, Staff (S2) was observed on camera in the living room area close to the patio door but did not respond to the patio door alarm. (Continued on 9099-C) Substantiated (Continued from 9099) There is no indication the door chime was not working. Multiple staff stated the patio door alarm was operational and loud on the day of the incident. At approximately 1900 hours R1’s fall pad alarm went off and an alert was immediately sent to the cell phones for employees working that shift: S2, Staff (S3), Staff (S4), Staff (S5) and Staff (S6). S1 stated S3 was responsible for monitoring the living room area and responding to R1’s fall pad alarm. S1 stated video recordings showed S3 standing inside the living room and failed to respond to the alarm notification. S3 remained in the same position until S3 heard R1 banging on the door at approximately 1932 hours. R1 was left outside unsupervised for approximately one and a half hours. S6 stated R1 was cold to the touch indicating R1 had been outside for an extended period of time. R1 was a known fall risk and required additional supervision. R1 was not permitted to be in the patio area alone due to being a fall risk. R1 was transported to the hospital by ambulance and diagnosed with a hip fracture requiring surgery and hospitalization. Based on the Department’s observations, interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the allegation that neglect by the facility resulted in resident’s injury is substantiated. California Code of Regulations, Health and Safety Code (1569.269 (a) (6), are being cited on the attached LIC 9099D. (Continued on 9099-C) (Continued from 9099-C) An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care. The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Additionally, it is alleged that the facility’s lighting in the patio area where R1 fell was not working properly. Facility records indicate that staff were aware of the lighting not being fully functional as maintenance requests were made for repairs on “End of Shift Reports” dated 9/13/2022, 1/30/2023 and 2/19/2023. Based on the Department’s observations, interviews conducted, and records reviewed found the facility’s poor lighting in the patio area contributed to R1’s fall and injury and therefore the allegation that the facility was in disrepair is substantiated. California Code of Regulations, (Title 22, Division 6, Chapter 8, Article 5 Physical Environments and Accommodations). Appeal rights given.the state’s words, verbatim · CDSS document, Jan 9, 2024 · control 21-AS-20230724142905

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Jan 9, 2024

(a) Residents…shall have…the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff…sufficient in number… **Based on records reviewed & interviews facility didn't comply w/reg above when R1 accessed patio unsupervised, fell, and sustained injury which posed an immediate risk to the health and safety of residents in care. **Immediate civil penalty of $500.00 was issued today for serious bodily injury.the state’s words, verbatim · CDSS document, Jan 9, 2024

Plan of correction: Licensee to submit a statement of understanding & submit a written plan of how they will ensure clients individual needs are met. Statement and detailed plan to be submitted to CCL by POC due date 01/10/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jan 9, 2024

87303 Maintenance and Operation:(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors… This requirement has not been met as evidenced by: Based on repair records lighting in patio area of Memory Care went unrepaired and contributed to the fall and injury of R1. This posed an immediate risk to the health and safety of the resident.the state’s words, verbatim · CDSS document, Jan 9, 2024

Plan of correction: Licensee to submit proof of repair to CCL by 1/10/2024, and submit plan of how repairs will be taken care of in a timely manner by 1/10/24.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct an inspection and deliver findings. During the course of the investigation the Department learned that the facility had failed to report the incident. Staff attempted to send the information to Community Care Licensing Regional Office, however it was not received. Staff received a "failed to send" notification and did not resend, leading the incident to go unreported as required per regulation. Deficiency cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8. Failure to correct the cited deficiency on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights given.the state’s words, verbatim · CDSS document, Jan 9, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211 · Plan of correction due date: Jan 9, 2024

87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency such reports as the Department may require...:(1)A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events specified... This report shall include the resident's name, age, sex and date of admission; date d disposition of the case. (B)Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as evidenced by: **Based on records reviewed which indicate that Incident Report was not sent in timely manner which poses a possible threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jan 9, 2024

Plan of correction: Administrator to submit the protocols staff will use to asssure that faxes and emails are sent correctly and in timely manner. POC due by 1/10/2024 to CCL.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. at Carlton Plaza of Davis on 01/09/24 at approximately 02:05 PM and met with Administrator Miriam Faris. There were 140 residents present. During facility tour with Administrator, facility was found to be clean and at a comfortable temperature of 74 F with all exits free from obstruction. At the time of inspection there was an activity in Memory Care with a large group of participants. Several residents' apartments, common areas, kitchen & food storage areas, Memory Care Unit, and outside sitting areas were inspected. Fire Extinguishers and Fire Protection System were inspected by Cosco Fire Protection on 11/27/23. All fire extinguishers in the facility were charged and tested on 11/27/23. Inspection of the kitchen showed there was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator and freezer were properly stored as per regulations on this day at the time of the visit. Toxins and dangerous items are stored in laundry room behind locked doors; providing inaccessibility to residents. There is also a chemical room off of the kitchen with a supply of cleaners, hygiene products and paper products available for clients which is locked and inaccessible to residents. Facility has an Infection Control Plan. All bathrooms were provided with hand soap and paper towels. Water temperature in bathrooms inspected measured 117 - 117.4 F. There were no deficiencies or citations issued during this inspection. Exit interview conducted with Administrator, Miriam Faris.the state’s words, verbatim · CDSS document, Jan 9, 2024